Syphilis and Congenital Syphilis -- United States, 1985-1988

In 1987, 35,241 cases of primary and secondary syphilis were
reported in the United States. The incidence of 14.6 cases per
100,000
persons equals that of 1982-- the highest rate since 1950. The 25%
increase over the 1986 rate was the largest single-year increase
since
1960. Because of this increase, the Public Health Service objective
to
reduce the incidence of primary and secondary syphilis to 7.0
cases/100,000 persons by 1990 (1,2) is unlikely to be achieved.

The increase in incidence was greatest for blacks and
Hispanics--groups for which incidence rates were already high
(Figure
1). In all racial/ethnic groups, increases were greater for females
than for males. From 1986 to 1987, the rate per 100,000 persons
15-64
years of age* increased 36% for black males (106.2 to 144.9), 43%
for
black females (55.5 to 79.4), 7% for Hispanic males (66.0 to 70.7),
and
24% for Hispanic females (17.8 to 22.0). In contrast, the rate for
white males decreased from 6.4 to 5.7, while for white females,
rates
increased 22% (2.2 to 2.6). The decrease among white males appears
to
be attributable to continuing decreases in syphilis incidence among
homosexual men (3).

In 1987, 57% of all reported U.S. cases were reported from
Florida,
California, and New York (Table 1). Six additional states and the
District of Columbia had 1987 incidence rates greater than
7.0/100,000
and had increases between 1985** and 1987 (Table 1). Eleven other
states had 1987 incidence rates greater than 7.0/100,000, but
incidence
did not increase from 1985 to 1987 (Figure 2). In Texas, rates
decreased steadily from 28.4/100,000 in 1985 to 18.4/100,000 in
1987.
In Nevada, Oregon, Delaware, Connecticut, and Pennsylvania,
syphilis
rates were below the 1990 objective of 7.0/100,000 in 1985.

The highest rates were reported in urban areas; this was
especially
apparent in New York and Pennsylvania. The 1987 rate per 100,000
persons was 63.5 in New York City, compared with 3.4 for the rest
of
New York, and 41.6 in Philadelphia, compared with 2.5 for the rest
of
Pennsylvania.

The national increase was first noted in the last half of 1986
(Figure 3), reflecting increases in Florida, California, and New
York.
The national increase peaked in the third quarter of 1987, then
plateaued through the first half of 1988, again reflecting trends
in
Florida, California, and New York. In other areas, such as
Connecticut,
Tennessee, and Nevada, rates continued to increase during the first
half of 1988. In Pennsylvania, where the incidence remained stable
but
elevated after a large increase in early 1986, the rate began to
increase again in 1988.

In the second half of 1987, the rate of congenital syphilis
cases
increased 21% to 10.5 cases per 100,000 live births. Most cases
occur
in areas with high syphilis incidence among adult women; in 1987,
67%
of all cases were reported from Florida, California, and New York.
Reported by: Participating city and state health depts and STD
control
programs. Div of Sexually Transmitted Diseases, Center for
Prevention
Svcs, CDC.

Editorial Note

Editorial Note: Decreases in syphilis and gonorrhea (3-7) in
homosexual men reflect changes in sexual behavior related to
controlling the spread of human immunodeficiency virus (HIV) in
that
population. The increases in incidence of syphilis described here
suggest that efforts to achieve similar behavioral changes in
minority
populations have not been successful (8). In addition, the evidence
is
strong, especially from Africa, that genital ulcer diseases like
syphilis increase the efficiency of sexual transmission of HIV
(9-12).

In March 1988, CDC reviewed the trends in syphilis with
sexually
transmitted disease experts from academic/medical institutions and
state and local health departments. This group identified the
following
three research priorities: 1) defining the current epidemiology of
syphilis, including the relationship with illegal drug use, 2)
evaluating and improving the effectiveness of different
intervention
methods, and 3) evaluating the effect of HIV coinfection on
syphilis
transmission.

The following interventions were suggested as being essential
if
these trends of increased syphilis rates are to be reversed:

Congenital syphilis, a preventable consequence of untreated
syphilis in pregnant women, causes fetal or perinatal death in 40%
of
affected pregnancies (13). Because increases in congenital syphilis
lag
behind increases in syphilis in women by about 1 year (14),
congenital
syphilis can be expected to continue to increase in frequency. This
may
be a particular problem for urban black and Hispanic women, who
have a
disproportionate increase in incidence and who are less likely than
white women to receive adequate prenatal care (15).

Congenital syphilis can be prevented by appropriate treatment
of
the mother during pregnancy (13). Syphilis screening in pregnant
and
childbearing-aged women is the best way to identify those who need
treatment. In addition, efforts must be made to remove obstacles
that
prevent women from receiving early prenatal care, especially in
areas
with high syphilis incidence.

References

Public Health Service. Promoting health/preventing disease:
objectives for the nation. Washington, DC: US Department of Health
and
Human Services, Public Health Service, 1980.

Ingram DD, Makuc D, Kleinman JC. National and state trends in
use
of prenatal care, 1970-83. Am J Public Health 1986;76:415-23.
*Ninety-nine percent of cases in 1987 occurred in persons 15-64
years
old.
**1985 was chosen as baseline for this comparison because, in
several
areas, the increases began during 1986.

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